GFHS Logo

Caring For Our Community

Population Health and Case Management

Kintegra’s Population Health and Case Management services identify patient populations within Kintegra and focus on enhancing quality, providing resources and improving health outcomes.

Linkage to Care and Resources :  Working in collaboration with local hospital system, Kintegra Case Managers identify  uninsured patients who do not have a primary care provider, and help to link these patients to care at Kintegra.  By identifying social determinants of health that can contribute to this populations’ health challenges, the team can  link them to key community resources, provide referrals to HealthNet Gaston, and work with the diabetic population on A1C control.

Leading Change:  At-Home Care Pilot: Kintegra has been selected by the National Association of Community Health Centers (NACHC) as 1 of 20 Community Health Centers in 16 states  to participate in this ilot program which offers patients their own self-care tools and remote patient monitoring to prevent unnecessary health problems.  Patients received BP cuffs, scales, A1C testing supplies, fecal occult testing kits and thermometers. Case Managers work with this population to help manage weight, BP and A1C. The project is called, “Leading Change: Transforming At-Home Care”.

Panel Manager Team: Team of RN’s and LPN’s that are embedded in all our Medical Clinics to provide care coordination, improve quality and enhance the patient experience. They work closely with all of our partnerships and directly with patients to improve patient care. They work closely with our providers to complete Medicare Wellness visits and Transitions of Care